Healthcare Provider Details

I. General information

NPI: 1891167987
Provider Name (Legal Business Name): MAYREN FRAGUELA-LAM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2015
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10691 N KENDALL DR STE 312
MIAMI FL
33176-1551
US

IV. Provider business mailing address

725 NW 129TH PL
MIAMI FL
33182-2354
US

V. Phone/Fax

Practice location:
  • Phone: 786-592-8470
  • Fax: 786-453-1583
Mailing address:
  • Phone: 786-344-5626
  • Fax: 786-453-1583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13231
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW13231
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberSW13231
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: